Customer Name:________________________
Address:______________________________
_____________________________________
_____________________________________
Email:_________________________________

Contact:_________________
Phone:__________________
Ship:_______
Via:________
Wassco Corporation (Est. 1992)
515 S. 25th West Ave.
Tulsa, OK 74127
(918) 834-4444
(918) 832-8946 Fax
Fax Order to 918-832-8946

Qty Product Text Each Total
Qty Silicon Wristbands      
Qty Tooling/Setup       
Text:______________________________________________________________________
Qty: __________ Youth          Color(s):_________________________________
Qty: __________ Adult           Color(s):_________________________________
Inside Band Text (Add $100):________________________________  
Qty Product Text Each Total
Qty Silicon Wristbands      
Qty Tooling/Setup       
Text:______________________________________________________________________
Qty: __________ Youth          Color(s):_________________________________
Qty: __________ Adult           Color(s):_________________________________
Inside Band Text (Add $100):________________________________  
Payment Method
Amex Mastercard Discover Visa
Card #________________________________________________
Expiration Date:___________________
CVV:____________ (3 or 4 Digit Security # located on back of card)
Sub-Total:  
Freight:  
Total:  
Amount Paid:  
Amount Due:  
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